WVCTSI Project ECHO
Hepatitis C
SUD
Psychiatry
Chronic Lung Disease
HIV
Endo
Campus Mental Health
COVID-19
PPW SUD
Statewide Antimicrobial Stewardship
Disclosure Statement
PLEASE NOTE that Project ECHO® case consultations do not create or otherwise establish a provider-patient relationship between any WVU clinician and any patient whose case is being presented in a Project ECHO setting. Always use ECHO ID# when presenting a patient in clinic. Sharing patient name, initials or other identifying information violates HIPAA privacy laws.
Hepatitis C Case Presentation Form
Presentation Date:
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Site
Site contact email address
Clinician
General Information/Demographics
Visit Date
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Patient age
Patient gender
M
F
Patient ethnicity - Hispanic or Latino
Y
N
Patient race
American Indian-Alaska Native
Asian
Black-African American
Native Hawaiian-Pacific Islander
White
Patient insurance
None
Medicare
Medicaid-MCO
Commercial Health Insurance
Other
Medicaid-MCO Desc
Medicare Desc
Commercial Health Insurance Desc
Other Insurance Desc
Case Presentation
HPI and Social History
Comorbidities
Relevant Physical Exam and Lab Results
All Medications
Prior Treatment History
Lyme Disease Signs, Symptoms, and Information
Hepatitis Vaccinations
Is patient immune to hepatitis A?
Yes
No
Hep A immunity notes
Is patient immune to hepatitis B?
Yes
No
Hep B immunity notes
Type of Cancer
Body Mass Index
Height
cm
in
Weight
kg
lbs
BMI
Basic Laboratory Results
Date of Lab Draw
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WBC
ANC
HGB
HCT
Platelets
Creatinine
Glucose
Protime
INR
Albumin
ALT
AST
Alk Phos
T. Bili
Direct Bili
Total Prot
APRI
Child-Turcotte-Pugh Classification
MELD Score
TSH
Hemoglobin A1C
Urinalysis
Additional Laboratory Results
Fe
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TIBC
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Ferritin
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Vitamin D 25-OH
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AFP
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HIV Ab
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HCV Genotype
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HCV Viral Load
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Serum Fibrosis Biomarker
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Other Lab
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Other Lab
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Other Lab
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Other Lab
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Other Lab
Lab other 5 date
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Lab other 5 desc
Additional Information
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Instructions
If you have any questions regarding the ECHO project, please send an email to
Jay Mason
,
Mithra Mohtasham
, or
Elisabeth Minnick
.